Today, it is no longer a question of whether one is simply HIV-positive or HIV-negative. Now there are additional statuses like Poz Undetectable and Neg on PreP. The need to discriminate based solely on status is becoming more and more irrelevant. Sure, serosorting, the sexual pairing of like statuses (positive/positive, negative/negative) worked in the 2000s, but medical technology has advanced. While a cure is edging ever closer, our current most effective tools against HIV are condoms and its younger brother PrEP. Let’s not forget that abstinence is still the most effective way to eliminate HIV transmission, however that’s neither fun nor realistic for many of us.
PrEP
PrEP stands for Pre-Exposure Prophylactic Treatment and currently comes in the form of a pill called Truvada. It works like birth control in the sense that it’s taken daily to reduce the risk of HIV transmission. Also like birth control, the pill does not protect against transmission of other STIs including chlamydia, gonorrhea, and syphilis.
How effective is it?
Various studies report different statistics, but the Centers for Disease Control & Prevention reports an efficacy rate of 92% while other analyses indicate that drug levels corresponding to daily use are associated with a 99% protection rate against HIV (PrepFacts.org).
If your plan is to use PrEP around the times you have sex, you’ll have to know when that will be. A recent study showed that PrEP is still reasonably effective only taken on days before and after sex. However, since the people in the study had sex as frequently as once a week, dosing only when one foresees sex clearly has potential problematic concerns. For maximum protection, PrEP should be taken at least 7 days before anal sex and at least 21 days before vaginal sex. The protection rate is still high when taken at least four days per week, and taking PrEP every day allows for more elasticity if doses are missed.
TasP
TasP stands for Treatment as Prevention and refers to HIV prevention methods that use antiretroviral treatment (ART) to reduce the viral load in the blood and semen of persons living with HIV to undetectable levels. Stated simply, one who tests positive for HIV can take medication to suppress the amount of virus in the body. This suppression of the virus makes the likelihood of transmission almost nonexistent. This is more commonly referred to as the “test and treat strategy,” and is a fairly new concept. When I tested positive in 2007, my doctor didn’t recommend taking meds until absolutely necessary. Because of this, my body contained a high amount of the HIV virus and the virus could still be transmitted to others. Treating the virus immediately suppresses the virus to a point where it is no longer transmittable. A recent study has confirmed this theory stating, “No one with an undetectable viral load, gay or heterosexual, transmits HIV.” (AIDSmap.com) In fact, it is statistically safer to have condomless sex with an undetectable HIVpositive partner than it is with someone alleging a negative status. This is due to the incubation period of the virus varying from three to six months, which may cause an HIV test to be inaccurate. Minor daily flux in viral load has not been shown to significantly increase risk of transmission. Overall, TasP reduces the viral load in the community at large, and PrEP reduces transmission as an additional or alternative form of safer sex practice.
So does this mean throw away the rubbers and get on the pill?
Not necessarily. The politically correct response is that PrEP is most effective when used in addition to condoms. While a missed dose is not going to significantly reduce your prevention, PrEP should be taken consistently every day. A missed dose can be taken later in the day and alternatively, Truvada is also used as post exposure prophylactic treatment. Contrast the dangers of missing a dose of PrEP to forgetting to wear a condom in the heat of passion. It happens, but this is where PrEP adds an additional layer of protection that a condom-only approach simply cannot provide.
Can you use PrEP without condoms?
Let’s cut through the politically correct BS and give you a real answer: YES you can use PrEP without condoms. Although I (and every healthcare professional) will tell you that PrEP provides the highest amount of protection when used in unison with condoms. Research has shown that the pill is just as effective, if not more effective, in preventing the transmission of HIV. Remember it does not prevent other types of STIs.
Facing facts
The reality of the situation is that there have always been people who are resistant to condom usage, whatever the reason (serodiscordant relationships, monogamous relationships, etc). A condom-only methodology still fails certain at-risk groups, but PrEP can help fill the transmission gap by offering an alternative method of prevention. PrEP represents an opportunity to modernize and redefine what safer sex means in modern day context.
“If you bareback, you’re going to die!”
This is a hard concept for many of my generation to grasp, and unfortunately the symptoms and fears of the trauma of the ‘80s are often projected onto today’s generation without room for informed and meaningful choice. Barebacking is a natural expression of sexuality, yet it still carries with it a stigma since the HIV/AIDS epidemic of the 1980s. People fear what they don’t understand, and unfortunately, some members of the existing generation and survivors of the AIDS epidemic carry a fear born of quite a different experience of HIV than my generation.
The cost argument
While PrEP is expensive today, that’s how medications work at first. A patent allows a company to make a profit from its research, but eventually the formula falls into the public domain and cheaper generics become available. Arguing against PrEP due to cost is a legitimate concern, but one that will eventually subside. Furthermore, many social programs are recognizing the importance of PrEP in reducing HIV transmission and have started efforts to assist with the cost. For example, most students fall within the low-income requirements to qualify for Affordable Care Act that can provide PrEP at little cost or even for free. As more and more research supports PrEP’s effectiveness, I would anticipate more social funding to make it affordable and available to a larger number of people.
In addition, research has shown that “taking HIV pre-exposure prophylaxis does not lead to increased levels of sexual risk behavior among gay men…[and that] numbers of sexual partners fell, as did the proportion of men reporting unprotected anal sex.” (Journal of Acquired Immune Deficiency Syndromes.) The CDC endorses PrEP as an effective way to reduce national HIV transmission rates and a monthly injectable version of the drug is making its way through research and development.
A different sort of stigma
Openly gay actor Zachary Quinto recently said, “Today’s generation sees [HIV] more as something to live with and something to be much less fearful of. And that comes with a sense of, dare I say, laziness.” (OUT Magazine.) While I agree with his first premise, I beg to differ on the second. PrEP mobilizes gay men to be proactive about their sexual health and that is the antithesis of sitting back in the passenger seat. At the very least, PrEP encourages a discussion with your medical provider about safer sex practices, and once on PrEP, ongoing assessment and STI testing is recommended in three-month intervals. Because PrEP only protects against HIV, the regular testing helps to combat and bring awareness concerning other STIs. Social campaigns, such as #TruvadaWhore open a dialogue about safer sex practices with individuals and helps to reduce stigma surrounding choice. After all, PrEP may not be right for everyone, but it should be everyone’s right to access PrEP if so desired.
The reality of the situation is that HIV is no longer the life threatening experience it once was – so long as we do not let fear and judgment get in the way of prevention, testing, and treatment. A person living with HIV in 2015 can live a long and healthy life without imminent death and destruction hanging over their head.
While I respect the experience of those that have gone before, clinical evidence is telling us that there are other ways to prevent transmission. In this new era we all have a tremendous opportunity to enjoy sex again without shame and stigma.
Is PrEP right for you?
For more information visit PrEPfacts.org and talk to your medical provider. If you want it and your provider won’t give it to you, find someone who will.
For more information about PrEP, contact:
CENTRAL OUTREACH WELLNESS CENTER
127 Anderson St.
Pittsburgh, PA 15212
412-322-4151